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General NPI Number Information
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NPI Number | 1376602680
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Entity Type | Organization
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Legal Business Name | IDAHO STATE UNIVERSITY
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Dates
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Enumeration Date | 12/06/2006
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Last Update Date | 10/13/2025
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Provider Practice Location Address
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Address Line | 609 CLINIC RD
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City | CHALLIS
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State | ID
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Zip | 83226-0070
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Country | US
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Telephone | 208-879-4600
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Fax | 208-879-5379
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Provider Business Mailing Address
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Address Line | 990 S 8TH AVE STOP 8158
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City | POCATELLO
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State | ID
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Zip | 83201-4982
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Country | US
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Telephone | 208-282-2407
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Fax | 208-282-6150
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Authorized Official
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Title or Position | PHARMACY MANAGER
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Name | RIKKI TRUSSEL
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Credential | PHARMD
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Telephone | 208-282-3407
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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